Prevalence and progression of untreated periodontal disease in a young Indonesian population Timmerman, M.F.

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1 UvA-DARE (Digital Academic Repository) Prevalence and progression of untreated periodontal disease in a young Indonesian population Timmerman, M.F. Link to publication Citation for published version (APA): Timmerman, M. F. (2001). Prevalence and progression of untreated periodontal disease in a young Indonesian population General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam ( Download date: 23 Sep 2018

2 GENERAL INTRODUCTION CHAPTER 1

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4 INTRODUCTION A major objective of dental care is extending the life span of the dentition either by prevention or by treatment of dental diseases. The mean number of teeth present per person is therefore an important parameter in the assessment of the longevity of the dentition (Sheiham et al. 1969). It is generally accepted that the number of teeth decreases with age and that caries and periodontal disease are the main causes of tooth loss, although the relative impact of these two disease entities may vary in different population groups and geographic areas (Löe et al. 1978a). The data from the studies by Brekhus (1929) and Allen (1944) led many to suppose that the greatest single reason for tooth loss after the age of 40 years was periodontal disease. Later, this was confirmed in a survey in Winnipeg, Manitoba, by Trott & Cross (1966). However, their results also showed, that the percentage of teeth lost due to periodontitis was higher than the percentage of patients, who lost teeth due to periodontitis. In other words, with regard to periodontitis, relatively many teeth were lost in relatively few patients. In a study of elderly people in Iowa, it was found that the distribution of tooth loss over an 18-month period was highly skewed (Hunt et al. 1988). The same was found in a study over a period of 28 years in Tecumseh (Burt et al ). In this particular study, 14.4% of the population became edentulous. This group accounted for 94% of all teeth lost during the study period. Among those who remained dentate, 1 3.8% of the persons lost teeth. They accounted for 60.2% of all teeth that were lost in dentate persons in that period. These data invite to the conclusion, that a minority of the population appears to be susceptible to extensive tooth loss, just as a minority appears susceptible to severe manifestations of caries (US Public Health Service 1 981, Graves et al 1 986) and periodontal disease (Löe et al. 1986, US Public Health Service 1987). However, tooth loss in itself is not a disease. The question that arises, is the extent to which this skewed distribution reflects social factors, as well as the underlying diseases. Studies seeking reasons for tooth loss have not probed this issue (Ainamo et al , Bouma et al , Cahen et al. 1985, Kay & Blinkhorn 1986, Bailit et al. 1987, Manji et al. 1988, Hunt et al 1988, Chauncey et al. 1989, Niessen & Weyant 1989). A principal finding in these studies is, that periodontal disease is not as important a reason for tooth loss as once thought, but many questions on the relative impact of disease, 17

5 CHAPTER 1 patient attitudes, and treatment philosophy on tooth loss remain unanswered (Weintraub & Burt 1985). Epidemiologic surveys conducted throughout the world point to the almost universal distribution of caries and periodontal diseases (Rüssel 1967). Most studies have found that periodontitis affects a significant percent of individuals before the age of 20 and affecting the majority of the adult population after the age of years. Studies report that the prevalence and average severity of periodontitis, increased with age for groups of individuals until virtually all middleaged people had the disease (for review see Scherp 1964, Brown & Löe 1993). While a large proportion of the population is susceptible to periodontitis, it appears that there is a small segment of the population that is susceptible to severe forms of periodontitis. This observation leads to the proposal that there are susceptibility or risk factors that modulate susceptibility to destructive periodontitis. The susceptibility of individuals appears to vary greatly depending upon which risk factors are operative (Genco 1996). A risk factor for periodontal disease is an environmental, behavioral, or biologic factor confirmed by temporal sequence, usually longitudinal studies, which if present, directly increases the probability of a disease occurring, and if absent, reduces this probability. Risk factors are part of the causal chain, or expose the host to the causal chain. Once disease occurs, removal of a risk factor may not result in a cure (Last 1988, American Academy of Periodontology 1996). Some risk factors are modifiable, while others cannot be modified or cannot easily be modified. Those factors that cannot be modified are often called 'determinants' or background factors. 'Risk factor' often implies a modifiable condition. The term risk indicator is used to describe plausible correlates of disease identified in crosssectional studies or case-control studies, while risk factors are best applied to those correlates confirmed in longitudinal studies. Risk indicators are not always confirmed as risk factors in longitudinal studies (Beck 1994). The term 'risk marker' is used more in the predictive sense and usually refers to a risk factor, which is associated with an increased probability of disease in the future. Changes in our knowledge of the etiology of periodontal diseases, and the recognition of the potential importance of susceptibility factors as they affect initiation and progression of periodontitis, have led to intense study of specific risk factors for destructive periodontal disease. 18

6 INTRODUCTION Epidemiologic studies show more periodontal disease in older age groups than in younger groups (Marshall-Day et al. 1955, Schei et al. 1959, Abdellatif & Burt 1987, Miller et al. 1987, Grossi et al. 1994, Grossi et al. 1995). This may be caused by cumulative tissue destruction over a lifetime rather than an age-related, intrinsic deficiency or abnormality which affects periodontal susceptibility. More recent studies suggest that at least in the moderately elderly the rate of periodontal destruction is the same throughout adulthood ((Holm-Pedersen et al. 1975, Machtei et al. 1994). When considering the oral hygiene status, age is not of substantial influence on periodontal disease (Abdellatif & Burt 1 987). Only at older age (between 75 and 96) more severe increase of periodontal disease has been reported (Douglass et al , Fox et al ). At ages up to 75 years, age by it self does not seem to be an intrinsic risk factor. A consistent finding in all national surveys in the United States is that periodontal disease is more prevalent in males than in females (U.S. Public Health Service 1965, U.S. Public Health Service 1979, Miller et al. 1987). Risk analyses of periodontitis in other populations are not unanimous about gender as a risk factor (Umeda et al , Gamonal et al , Norderyd et al ). But, like in the United States, if a significant association is reported, males most often show a higher risk than females. Reasons for this have not been explored in detail, but are thought to be more a matter of differences in behaviourthan in genetic background (Position Paper AAP 1996). Socio-economic status was historically found to relate to gingivitis and poor oral hygiene (U.S. Public Health Service 1965, U.S. Public Health Service 1979). This does not account for periodontitis (Miller et al ). Both in developing countries (Russell 1962, Waerhaug 1967, Wertheimer et al. 1967) and in industrialized countries (Grossi et al. 1994, Grossi et al. 1995) it was found that lower socioeconomic status was not associated with severity of periodontitis. It is not clear how other factors like true genetic racial/ethnic influence and cultural factors confound in this multifaceted variable. Whereas oral hygiene measures correlate well with gingivitis, many cross-sectional studies show a poor correlation between levels of plaque and supragingival calculus and periodontitis (Löe et al , Cutress et al , Baelum et al , Baelum et al a, 1 988b, Ismail et al , Ismail et al , Lembariti et al , Löe et al. 1992, Okamoto et al. 1988). Subgingival calculus as a separate entity 19

7 CHAPTER 1 has not been studied epidemiologically. Plaque and calculus were discovered for their role in periodontal disease in the cross-sectional studies of the late fifties and early sixties (Lövdal et al. 1958, Ladavalya & Harris 1959, Schei et al. 1959, Mobley & Smith 1963). Controlled studies in Western populations show, that the amount of plaque has a low correlation with the amount of attachment loss measured (Lindhe et al. 1989, Badersten et al , Machtei et al 1 993, Grossi et al , Grossi et al ). Also the predictive value of the amount of plaque for future progression of periodontitis is low (Claffey et al , Haffajee et al ). On the other hand, in their 28-year longitudinal study on risk factors for tooth loss, Burt et al. (1 990) found that edentulous persons had higher baseline scores for plaque, calculus and gingivitis, then the age-matched dentate persons. Among dentate persons the baseline gingivitis score and the baseline number of teeth were risk factors for partial tooth loss. In this study periodontal attachment loss >4 mm and educational attainment were significant risk factors in the regression analysis. When considering the best predictor for future attachment loss, the amount of existing disease in relation to age seems to be the best choice (Haffajee et al , Grbic et al , Grbic & Lamster 1 992). However this is still an inexact procedure (Position Paper AAP 1996). A few members of the periodontal microflora have been considered as putative pathogens for initiation and progression of periodontal disease. Slots et al. (1 986) reported, in a retrospective study, a relationship between the presence of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis and Prevotella intermedia and progression of periodontal disease. Hence, the value of the presence of these 3 micro-organisms as a predictor for periodontal breakdown was investigated in adult cases with refractory periodontitis during a 12 months evaluation period. Progression of disease (attachment loss >2 mm) was not observed at sites without detectable levels of A. actinomycetemcomitans, P. gingivalis and P. intermedia (Wennström et al ). Also microbial epidemiologic studies have shed light on the role of specific periodontal micro-organisms in periodontal disease. Carlos et al. (1988) found the presence of Prevotella intermedia, along with gingival bleeding and calculus was correlated with attachment loss in a group of Navajo adolescents aged 1 4 to 19. An epidemiologic study of oral bacteria as risk indicators for periodontitis in older adults reported, 20

8 INTRODUCTION that the difference in the prevalence of periodontal disease between blacks and whites was explained, in part, by different prevalences of P. gingivalis and P. intermedia (Beck et al. 1992). Grossi et al. (1994, 1995) tested a panel of microorganisms including A. actinomycetemcomitans, B. fosythus, Campylobacter rectus, Capnocytophaga species, Eubacterium sabureum, F. nucleatum, P. gingivalis, and P. intermedia. Of these micro-organisms, only P. gingivalis and B. forsythus were associated with an increased risk for attachment loss after adjustment for age, plaque, smoking and diabetes. The same two micro-organisms were also identified as risk indicators for periodontal alveolar bone loss. As is apparent from all these studies, variables that may be accounted for as risk factors for periodontal disease are not unanimously found to be so. The complex, multifaceted structure of these variables and their confounding influence on the multifactorial disease process of periodontitis, may be the reason for the difficulty to assess the quality and quantity of the effects of these factors. A problem of performing studies in Western populations is that there is always some form of treatment effect involved. Ethical considerations do not allow for abstention of therapeutic measures in such a population. The effect of treatment influences the results of these studies to an extent that cannot be controlled for. Therefore, a longitudinal study was initiated in 1987 in a young population, which had not received regular dental care, in order to establish the role of possible clinical and microbiological risk factors for initiation and progression of periodontitis. In 1 987, all subjects in the age range of years, living in a small village on a tea estate on western Java, Indonesia, entered the study. The material presented in this thesis describes data on changes in the clinical periodontal condition of the study population over a 7 years period between 1987 and 1994 and the relationship with clinical parameters and with presence of various periodontal bacteria in the oral cavity both at the start and at the end of the investigation. 21

9 CHAPTER 1 REFERENCES Abdellatif, H.M. & Burt, B.A. (1987) An epidemiological investigation into the relative importance of age and oral hygiene status as determinants of periodontitis. Journal of Dental Research 66, Ainamo, J., Sarkki, L, Kuhalampi, M.L., Palolampi, L. & Piirto, O. (1984) The frequency of periodontal extractions in Finland. Community Dental Health 1, Allen, E.F. (1 944) Statistical study of the primary causes of extractions. Journal of Dental Research 23, American Academy of Periodontology (1996) Consensus report for periodontal diseases: epidemiology and diagnosis. Annals of Periodontology 1, Badersten, A., Nilveus, R. & Egelberg, J. (1990) Scores of plaque, bleeding, suppuration and probing depth to predict probing attachment loss. 5 years of observation following nonsurgical periodontal therapy. Journal of Clinical Periodontology 17, Baelum, V., Fejerskov, 0. & Karring, T. (1986) Oral hygiene, gingivitis and periodontal breakdown in adult Tanzanians. Journal Periodontal Research 21, Baelum, V., Fejerskov, 0. & Manji F. (1988) Periodontal diseases in adult Kenyans. Journal Clinical Periodontology 15, of Baelum, V., Wen-Min, L., Fejerskov, O. & Xia, C. (1 988) Tooth mortality and periodontal conditions in year-old Chinese. Scandinavian Journal of Dental Research 96, Bailit, H.L., Braun, R., Maryniuk, G.A. & Camp, P. (1987) Is periodontal disease the primary cause of tooth extraction in adults? Journal of the American Dental Association 114, Beck, J.D., A.W., Koch, G., Dunford, R.G., Zambon, J.J. & Genco, R.J. (1992) Evaluation of oral bacteria as risk indicators for periodontitis in older adults. Journal of Periodontology 63, Beck, J.D. (1 994) Methods of assessing risk for periodontitis and developing multifactorial models. Journal of Periodontology 65(Suppl), Bouma, J., Schaub, R.M. & Van de Poel, F. (1985) Periodontal status and total tooth extraction in a medium-sized city in the Netherlands. Community Dental and Oral Epidemiology 13,

10 INTRODUCTION Brekhus P.J. (1929) Dental disease and its relation to the loss of human teeth. Journal of the American Dental Association 16, Brown, L.J. & Löe, H. (1993) Prevalence, extent, severity and progression of periodontal disease. Per/odontology , Burt, B.A., Ismail, A.I., Morrison, E.C. & Beltran, E.D. (1990) Risk factors for tooth loss over a 28-year period. Journal of Dental Research 69, Cahen, P.M., Frank, R.M. & Turlot, J.C. (1985) A survey of the reasons for dental extractions in France. Journal of Dental Research 64, Carlos, J.P., Wolfe, M.D., Zambon, J.J. & Kingman, A. (1988) Periodontal disease in adolescents: some clinical and microbiologic correlates of attachment loss. Journal of Dental Research 67, Chauncey, H.H., Glass, R.L. & Alman, J.E. (1 989) Dental caries. Principal cause of tooth extraction in a sample of US male adults. Caries Research 23, Claffey, N., Nylund, K., Kiger, R., Garrett, S. & Egelberg, J. (1990) Diagnostic predictability of scores of plaque, bleeding, suppuration and probing depth for probing attachment loss. 3 1/2 years of observation following initial periodontal therapy. Journal of Clinical Periodontology 17, Cutress, T.W., Powell, R.N. & Ball, M.E. (1982) Differing profiles of periodontal disease in two similar South Pacific island populations. Community Dentistry and Oral Epidemiology 10, Davies, G.N. (1956) Dental conditions among the Polynesians of Papuka (Danger Island) of Dental Research 35, Journal Douglass, C.W., Jette, A.M., Fox, C.H., Tennstedt, S.L., Joshi, A., Feldman, H.A., McGuire, S.M. & McKinlay, J.B. (1993) Oral health status of the elderly in New England. Gerodonto/ogy 48, Fox, C.H., Jette, A.M., McGuire, S.M., Feldman, H.A. & Douglass, C.W. (1 994) Periodontal disease among New England elders. Journal of Periodontology 65, Gamonal, J.A., Lopez, N.J. & Aranda, W. (1998) Periodontal conditions and treatment needs, by CPITN, in the and year-old population in Santiago, Chile. International Dental Journal 48,

11 CHAPTER 1 Genco, R.J. (1996) Current view of risk factors for periodontal diseases. Journal of 67, Periodontology Graves, R.C., Bohannan, H.M., Disney, J.A., Stamm, J.W., Bader, J.D. & Abernathy, J.R. (1986) Recent dental caries and treatment patterns in US children. Journal of Public Health and Dentistry 46, Grbic, J.T., Lamster, LB., Celenti, R.S. & Fine, J.B. (1991) Risk indicators for future clinical attachment loss in adult periodontitis. Patient variables. Journal of Periodontology 62, Grbic, J.T. & Lamster, LB. (1992) Risk indicators for future clinical attachment loss in adult periodontitis. Tooth and site variables. Journal of Periodontology 63, Grossi, S.G., Zambon, J.J., Ho, A.W., Koch, G., Dunford, R.G., Machtei, E.E., Norderyd, O.M. & Genco, R.J. (1994) Assessment of risk for periodontal disease. I. Risk indicators for attachment loss. Journal of Periodontology 65, Grossi, S.G., Genco, R.J., Machtei, E.E., Ho, A.W., Koch, G., Dunford, R., Zambon, J.J. & Hausmann, E. (1995) Assessment of risk for periodontal disease. II. Risk indicators for alveolar bone loss. Journal of Periodontology 66, Haffajee, A.D., Socransky, S.S. & Goodson, J.M. (1983) Clinical parameters as predictors of destructive periodontal disease activity. Journal of Clinical Periodontology 10, Haffajee, A.D., Socransky, S.S., Lindhe, J., Kent, R.L., Okamoto, H. & Yoneyama, T. (1991) Clinical risk indicators for periodontal attachment loss. Journal of Clinical Periodontology 18, Holm-Pedersen, P., Agerbaek, N. & Theilade, E. (1975) Experimental gingivitis in young and elderly individuals. Journal of Clinical Periodontology 2, Hunt, R.J., Hand, J.S., Kohout, F.J. & Beck, J.D. (1988) Incidence of tooth loss among elderly lowans. American Journal of Public Health 78, Ismail, A.I., Eklund, S.A., Burt, B.A. & Calderone, J.J. (1986) Prevalence of deep periodontal pockets in New Mexico adults aged 27 to 74 years. Journal Public Health Dentistry 46, Ismail, A.I., Burt, B.A. & Brunelle, J.A. (1987) Prevalence of total tooth loss, dental caries, and periodontal disease in Mexican-American adults: results from the southwestern HHANES. Journal of Dental Research 66,

12 INTRODUCTION Kay, E.J. & Blinkhorn, A.S. (1986) The reasons underlying the extraction of teeth in Scotland. British Dental Journal 160, Ladavalya, M.R.N. & Harris, R. (1959) A study of the gingival and periodontal conditions of a group of people in Chieng Mai Province. Journal of Periodontology, 30, Last, J.M. (1988) A dictionary of epidemiology. 2nd edition, New York, NY: Oxford University Press. Lembariti, B.S., Frencken, J.E. & Pilot T. (1988) Prevalence and severity of periodontal conditions among adults in urban and rural Morogoro, Tanzania. Community Dentistry and Oral Epidemiology 16, Lindhe, J., Okamoto, H., Yoneyama, T., Haffajee, A. & Socransky, S.S. (1989) Longitudinal changes in periodontal disease in untreated subjects. Journal of Clinical Periodontology 16, Löe, H., Anerud, A., Boysen, H. & Smith, M. (1978a) The natural history of periodontal disease in man. The rate of periodontal destruction before 40 years of age. Journal of Periodontology 49, Löe, H., Ânerud, Â., Boysen, H. & Smith, M. (1978b), The natural history of periodontal disease in man. Tooth mortality rates before 40 years of age. Journal of Periodontal Research 13, Löe, H., Ânerud, Â., Boysen, H. & Morrison, E. (1986) Natural history of periodontal disease in man: rapid, moderate and no loss of attachment in Sri Lankan labourers 14 to 46 years of age. Journal of Clinical Periodontology 13, Löe, H. & Morrisson, E. (1990) Epidemiology of periodontal of disease. In Contemporary periodontics, eds. Genco, R.J., Goldman, H.M. & Cohen, D.W., 1st edition, pp , St. Louis: Mosby. Löe, H., Ânerud, Â. & Boysen, H. (1992) The natural history of periodontal disease in man: prevalence, severity, and extent of gingival recession. Journal of Periodontology 63, Lövdal, A., Arno, A. & Waerhaug, J. (1958) Incidence of clinical manifestations of periodontal disease in the light of oral hygiene and calculus formation. Journal of the American Dental Association, 56,

13 CHAPTER 1 Machtei, E.E., Christersson, L.A., Zambon, J.J., Hausmann, E., Grossi, S.G., Dunford, R. & Genco, R.J. (1993) Alternative methods for screening periodontal disease in adults. Journal of Clinical Per/odontology 20, Machtei, E.E., Dunford, R.G., Grossi, S.G. & Genco, R.J. (1994) Cumulative nature of periodontal attachment loss. Journal of Periodontal Research 29, Manji, F., Baelum, V. & Fejerskov, 0. (1988) Tooth mortality in an adult rural population in Kenya. Journal of Dental Research 67, Marshall-Day, CD., Stephens R.G. & Quigley, L.F.Jr. (1955) Periodontal disease: prevalence and incidence. Journal of Periodonto/ogy 26, Miller, A.J., Brunelle, J.A., Carlos, J.P., Brown, L.J. & Löe, H. (1 987) Oral health of United States adults: National findings. Bethesda, MD National Institute of Dental Research, NIH, publication no Mobley, E. & Smith, S.H. (1 963) Some social and economic factors relating to periodontal disease among young negroes: No.1. Journal of the American Dental Association, 66, Niessen, L.C. & Weyant, R.J. (1 989) Causes of tooth loss in a veteran population. Journal Health and Dentistry 49, of Public Norderyd, 0., Hugoson, A. & Grusovin, G. (1999) Risk of severe periodontal disease in a Swedish adult population. A longitudinal study. Journal of Clinical Periodonto/ogy 26, Okamoto, H., Yoneyama, T., Lindhe, J., Haffajee, A. & Socransky, S. (1988) Methods of evaluating periodontal disease data in epidemiological research. Journal of Clinical Periodonto/ogy 15, Olson, B. (1978) Periodontal disease and oral hygiene in Arussi province, Ethiopia. Dentistry and Oral Epidemiology 6, Community Position Paper of the American Academy of Periodontology (1996) Epidemiology of periodontal diseases. Journal of Periodontology 67, Russell, A.L. (1962) Periodontal disease in well and mallnourished populations. Archives of Environment and Health, 5,

14 INTRODUCTION Schei, O., Waerhaug, J., Lövdal, A. & Arno, A. (1959) Alveolar bone loss as related to oral hygiene and age. Journal of Periodontology, 30, Scherp, H.W. (1964) Current concepts in periodontal disease research: Epidemiological contributions. Journal of the American Dental Association 68, Sheiham, A., Hobdell, M.H. & Cowell, CR. (1969) Patterns of tooth loss in British populations. Studies on industrial populations. British Dental Journal 126, Slots, J. (1986) Bacterial specificity in adult periodontitis. A summary of recent work. Journal Clinical Periodontology 13, of Slots, J., Bragd, L., Wikström, M. & Déhlen, G. (1986) The occurrence of Actinobacillus actinomycetemcomitans, Bacteroides gingiva/is and Bacteroides intermedius in destructive periodontal disease in adults. Journal Clinical Periodontology 13, Trott, J.R. & Cross, H.G. (1 966) An analysis of the principle reasons for tooth extractions in 1813 patients in Manitoba. Dental Practitioner, 17: Umeda, M., Chen, C, Bakker, I., Contreras, A., Morrison, J.L. & Slots, J. (1998) Risk indicators for harboring periodontal pathogens. Journal of Periodontology 69, U.S. Public Health Service, National Center for Health Statistics (1965) Periodontal disease in adults, United States PHS publication no Series II, No 12 Washington DC: Governement Printing Office. U.S. Public Health Service, National Center for Health Statistics (1979) Basic data on dental health examination findings of persons 1-75 years; United States, DHEW publication no. (PHS) , Series 11, No Washington DC: Governement Printing Office. U.S. Public Health Service, National Institute of Dental Research (1981) The prevalence of dental caries in United States children. Bethesda, MD, NIH Publication No U.S. Public Health Service, National Institute of Dental Research (1987) Oral health United States adults. Bethesda, MD, NIH Publication No Waerhaug, J. (1967) Prevalence of periodontal disease in Ceylon. Association with age, sex, oral hygiene, socio-economic factors, vitamin deficiencies, malnutrition, betel and tobacco consumption and ethnic group. Final report. Acta Odontologica Scandinavica 25,

15 CHAPTER 1 Weintraub, J.A. & Burt, B.A. (1985) Oral health status in the United States: tooth loss and edentulism. Journal of Dental Education 49, Wennström, J.L., Dahlén, G., Svensson, J. & Nyman, S. (1987) Actinobacillus actinomycetemcomitans, Bacteroides gingivalis and Bacteroides intermedius: predictors of attachment loss? Oral Microbiology and Immunology 2, Wertheimer, F.W., Brewster, R.H. & White, C.L. (1967) Periodontal disease and nutrition in Trinidad. Journal of Periodontology 38,